Gregory complains about his insurer not agreeing to pay for experimental treatment under his private medical insurance policy.
Gregory had lymphoma and needed surgery. His treating consultant wanted to carry out an experimental treatment, by using a robot.
Shortly before the surgery, the insurer said they wouldn’t approve the use of the robot. Gregory went ahead with the surgery and the insurer paid the bill, apart from the additional cost of the robot.
Gregory felt his insurer acted unreasonably considering his circumstances and made a complaint. Unhappy with the insurer’s response, he referred his complaint to us.
What we said
We got information from Gregory’s treating consultant about why he thought a robot needed to be used in Gregory’s case. We looked into the journal articles he referred us to and checked the NICE guidelines. We also checked what the insurer had said to Gregory about how likely it was this treatment would be covered, and if it had managed Gregory’s expectations about this.
We explained to Gregory there was no evidence in the medical journals that showed the robot was effective in treating his condition. It also hadn’t been approved by NICE as safe and effective.
So we didn’t think it was unreasonable for the insurer to decline to cover the cost of the robot and pay the remainder of the bill as it was under the policy limit.
We told Gregory we thought the claim settlement his insurer had offered was fair.
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